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Radiology Referral Form.Pdf DEPARTMENT OF RADIOLOGY Central Scheduling Phone: 832-TC4-XRAY [832-824-9729] PEDIATRIC Fax: 832-825-5306 ¨ ROUTINE ¨ IS A CALL REPORT REQUESTED AFTER EXAM IS READ BY THE RADIOLOGIST? ¨ ASAP [PERFORMED WITHIN 2-4 HOURS] PLEASE PROVIDE PHONE # TO CALL: _______________________________________ ¨ STAT [LIFE OR LIMB THREATENING; PERFORM IMMEDIATELY] PHYSICIAN ORDER FORM Page 1 of 2 Patient’s Name: Last First M.I. D.O.B.: / / Home Cell Phone: Phone: mm dd yyyy Address: Street Address City State ZIP Guarantor Email: Insurance/Medicaid Plan: Policy & Group #: Authorization #: Please also fax copy of insurance card front & back with this order Reason for Exam: (Signs, Symptoms, Chief Complaint): Ordering Physician’s Office Contact: ___________________________________________ Signature: Practice Phone: __________________________________________ Backline Phone: __________________________________________ Physician Name: _____________________________________________________ Fax: ____________________________________________________ Date/Time signed: ____________________________________________________ SPECIAL INSTRUCTIONS: ¨ Schedule for Date/Time: ________________________ ¨ Send CD with patient ¨ Research Patient PCP Name (if different): _______________________________________________ Order Comments: ______________________________________________________ X-RAY ¨ Neck Soft Tissue ¨ Skull [< 4 views] ¨ DXA Bone Density ¨ Hips ¨ L ¨ R ¨ Clavicle, Bilateral [2 views] ¨ C-Spine [3 views or less] ¨ Leg Length [Scanogram] ¨ Femur [2 views] ¨ L ¨ R ¨ Clavicle, Unilateral ¨ C-Spine [Flex-Ext] ¨ Shoulder ¨ L ¨ R ¨ Knee [3 views] ¨ L ¨ R ¨ Chest [2 views] ¨ T-Spine [2 views] ¨ Humerus [2 views] ¨ L ¨ R ¨ Tibia/Fibula [2 views] ¨ L ¨ R ¨ Infant Chest w/ Abdomen [< 12 months] ¨ Spine Scoliosis [2 views] ¨ Forearm [2 views] ¨ L ¨ R ¨ Ankle ¨ L ¨ R ¨ Ribs Unilateral ¨ EOS Spine Scoliosis [ONLY Main Campus] ¨ Elbow [3 views] ¨ L ¨ R ¨ Foot [3 views] ¨ L ¨ R ¨ Ribs Bilateral ¨ L-Spine [Flex-Ext] ¨ Wrist [3 views] ¨ L ¨ R ¨ Abdomen [1 view] ¨ L-Spine [2-3 views] ¨ Hand [3 views] ¨ L ¨ R ¨ Abdomen [2 views] ¨ L-Spine [4+ views] ¨ Finger(s) Specify ___________ ¨ L ¨ R ¨ Hip Bilateral [3-4 views] ¨ Skeletal Survey Genetics ¨ Toe(s) [2 views] Specify ______ ¨ L ¨ R ¨ Shunt Series ¨ Bone Age [Hand and Wrist] [Left Only] ¨ Sinuses FLUOROSCOPY / OTHER MUSCULOSKELETAL ¨ Esophagram ¨ Nasojejunal Placement ¨ Arthrocentesis: MRI (Arthrogram) ¨ L ¨ R Shoulder/Hip/Knee/Elbow/Wrist/Finger/Toe/Ankle + Injection ¨ Upper GI [with KUB] ¨ GI Tube Check ¨ Steroid Injection ¨ L ¨ R Shoulder/Hip/Knee/Elbow/Wrist/Finger/Toe/Ankle ¨ Upper GI [without KUB] ¨ Swallow Study w/Speech ¨ Tendon Sheath Injection ¨ L ¨ R Shoulder/Hip/Knee/Elbow/Wrist/Finger/Toe/Ankle ¨ Palate Studt ¨ Voiding Cystourethrogram [VCUG] ¨ Ganglion Cyst Aspiration ¨ L ¨ R Shoulder/Hip/Knee/Elbow/Wrist/Finger/Toe/Ankle ¨ Contrast Enema ¨ Therapeutic Enema ¨ Upper GI SBFT [espohagus through colon] ULTRASOUND ¨ Abdomen Complete ¨ Head Neck Soft Tissues ¨ Penile Doppler ¨ Upper Extremity Arterial Doppler, Bilateral ¨ Abdomen Complete w/ Doppler ¨ Head Neonatal ¨ Pylorus ¨ Upper Extremity Arterial Doppler, Unilateral ¨ L ¨ R ¨ Abdominal Abscess, Fluid Collections ¨ Infant Hips w/ Manipulation ¨ Soft Tissue Extremity ¨ Upper Extremity Venous Doppler, Bilateral ¨ Abdominal Wall ¨ Infant Hips w/o Manipulation ¨ Soft Tissue Lower Back ¨ Upper Extremity Venous Doppler, Unilateral ¨ L ¨ R ¨ Appendix ¨ Intussusception ¨ Soft Tissue Torso ¨ Lower Extremity Arterial Doppler, Unilateral ¨ L ¨ R ¨ Breast Unilateral, Limited ¨ L ¨ R ¨ Joint Effusion ¨ Spinal Canal and Contents ¨ Lower Extremity Arterial Doppler, Bilateral ¨ Carotid Doppler, Bilateral ¨ Renal Complete ¨ Thyroid ¨ Lower Extremity Venous Doppler, Unilateral ¨ L ¨ R ¨ Carotid Doppler, Unilateral ¨ L ¨ R ¨ Renal Limited ¨ Transplanted Kidney w/ Doppler ¨ Lower Extremity Venous Doppler, Bilateral ¨ Chest Effusion ¨ Renal Doppler ¨ Transplanted Kidney w/o Doppler ¨ Diaphragm ¨ Right Upper Quadrant w/ Doppler ¨ Doppler Aorta, Inferior Cava ¨ Right Upper Quadrant Gallbladder ¨ Female Pelvis w/ Doppler ¨ Scrotum and Testicles w/ Doppler ¨ Female Pelvis w/o Doppler ¨ Scrotum and Testicles w/o Doppler DEPARTMENT OF RADIOLOGY Central Scheduling Phone: 832-TC4-XRAY [832-824-9729] PEDIATRIC Fax: 832-825-5306 ¨ ROUTINE ¨ IS A CALL REPORT REQUESTED AFTER EXAM IS READ BY THE RADIOLOGIST? ¨ ASAP [PERFORMED WITHIN 2-4 HOURS] PLEASE PROVIDE PHONE # TO CALL: _______________________________________ ¨ STAT [LIFE OR LIMB THREATENING; PERFORM IMMEDIATELY] ORDERS FOR ADVANCED IMAGING Page 2 of 2 CT ¨ Without Contrast ¨ With Contrast CT ANGIOGRAPHY ¨ Head ¨ Abdomen/Pelvis ¨ Shoulder ¨ L ¨ R ¨ Hips ¨ L ¨ R ¨ Head ¨ Orbit ¨ 3D Rendering ¨ Humerus ¨ L ¨ R ¨ Femur ¨ L ¨ R ¨ Neck ¨ Temporal Bones ¨ Abdomen ¨ Forearm ¨ L ¨ R ¨ Knee ¨ L ¨ R ¨ Chest/PE ¨ Maxillofacial ¨ Chest ¨ Elbow ¨ L ¨ R ¨ Tibia/Fibula ¨ L ¨ R ¨ Abdominal Aorta ¨ Soft Tissue Neck ¨ Lumbar Spine ¨ Wrist ¨ L ¨ R ¨ Ankle ¨ L ¨ R ¨ Abdomen/Pelvis ¨ Paranasal Sinus ¨ Thoracic Spine ¨ Hand ¨ L ¨ R ¨ Foot ¨ L ¨ R ¨ Upper Extremity Unilateral ¨ L ¨ R ¨ Paranasal Sinus Fusion ¨ Cervical Spine ¨ Finger(s) Specify ________ ¨ L ¨ R ¨ Upper Extremity Bilateral ¨ Chest/Abdomen/Pelvis ¨ Toe(s) Specify __________ ¨ L ¨ R ¨ Lower Extremity Unilateral ¨ L ¨ R ¨ Hips and Pelvis ¨ Lower Extremity Bilateral MRI ¨ Without Contrast ¨ With AND Without Contrast ¨ Brain ¨ Chest ¨ Lumbar Spine ¨ Hips ¨ L ¨ R ¨ Brain Shunt Study ¨ Cardiac ¨ Complete Spine ¨ Femur ¨ L ¨ R ¨ MRI Spectroscopy ¨ Cardiac Stress ¨ Brachial Plexus ¨ Knee ¨ L ¨ R ¨ BRAIN Functional MRI ¨ Cardiac without [Iron Quantification] ¨ Shoulder ¨ L ¨ R ¨ Tibia/Fibula ¨ L ¨ R ¨ Face ¨ Abdomen ¨ Humerus ¨ L ¨ R ¨ Ankle ¨ L ¨ R ¨ IACs ¨ Hips and Pelvis ¨ Forearm ¨ L ¨ R ¨ Foot ¨ L ¨ R ¨ Orbits ¨ Abdomen without [Iron Quantification ¨ Elbow ¨ L ¨ R ¨ Toe(s) Specify _______________ ¨ L ¨ R ¨ Pituitary ¨ Enterography ¨ Wrist ¨ L ¨ R ¨ Neck ¨ Cervical Spine ¨ Hand ¨ L ¨ R ¨ Temporal mandibular joints ¨ Thoracic Spine ¨ Finger(s) Specify _____________ ¨ L ¨ R MRA ¨ Brain ¨ Neck ¨ Chest ¨ Abdomen ¨ Pelvis ¨ Extremity [Upper/Lower] ¨ L ¨ R _____________ ¨ Other _____________ MRV ¨ Brain ¨ Neck ¨ Chest ¨ Abdomen ¨ Pelvis ¨ Extremity [Upper/Lower] ¨ L ¨ R _____________ ¨ Other _____________ NUCLEAR RADIOLOGY ¨ Thyroid Scan w/ Uptake-Multi [I-123] ¨ Bone Scan Whole Body ¨ Quantitative Differential Pulmonary Perfusion & Vent w/ Image ¨ Thyroid Treatment/Ablation [I-131] ¨ Bone Scan w/ SPECT ¨ Lung Scan Perfusion Particulate ¨ Hepatobiliary ¨ 3 Phase Bone Scan – Specify area _______________ ¨ MIBG ¨ Hepatobiliary w/ Gallbladder Ejection Fraction ¨ Renogram w/ Pharm [Lasix] ¨ PET F-DOPA ¨ Gastric Emptying [Liquid] ¨ Renal Imaging [DMSA; under 12 months] ¨ Myocardial Rest/Stress ¨ Gastric Emptying [Solid] ¨ Cystogram ¨ Gastroesophageal Reflux ¨ Meckel’s Scan ¨ GFR ¨ GI Bleed ¨ White Blood Cell [WBC] ¨ Octreotide ¨ Lymphoscintigraphy ¨ PET/CT ¨ Brain ¨ Whole Body INTERVENTIONAL RADIOLOGY ¨ Angio Specify ___________________ ¨ Cholangiogram ¨ GJ Tube Conversion ¨ PICC ¨ L ¨ R ¨ Veno Specify ___________________ ¨ Angioplasty [Peripheral/Visceral] ¨ GJ Tube Exchange ¨ Exchange ¨ Radiofrequency Ablation [RFA] ¨ Lumbar Puncture ¨ Sialogram ¨ Placement ¨ Interventional Radiology Consult ¨ Hemorrhage/Lymphatic Embolization [Sclero] ¨ Tunnel Port Placement/Removal ¨ Removal ¨ Cryoablation ¨ Fine Needle Aspiration ¨ Thoracentesis ¨ Reposition ¨ Biopsy ¨ Whitaker Test ¨ Paracentesis ¨ Tunnel ¨ Pleura ¨ Biliary Drain [Cholangiogram] Placement/Removal ¨ Retroperitoneal Drain ¨ Nephrogram ¨ Renal ¨ Inferior Vena Cavagram [Transvaginal or Transrectal] ¨ Catheter Exchange, Nephrostomy ¨ Liver Percutaneous ¨ Embolization Specify _______________ ¨ Ureteral Stent Placement/Removal ¨ Drain Placement, Nephrostomy ¨ Bone Deep/Superficial ¨ Cerebral Angiogram Bilateral/Single ¨ Central Line Placement/Removal ¨ Thyroid ¨ Cerebral Interventions Bilateral/Unilateral ¨ Lung ¨ Chest Drain ¨ IVC Filter Placement/Removal 1488 Main Campus (in the Texas Medical Center) Texas Children’s Mark A. Wallace Tower West Tower Legacy Tower Hospital 6701 Fannin Street 6621 Fannin Street 6651 Main Street The Woodlands Houston, TX 77030 Houston, TX 77030 Houston, TX 77030 99 Community Hospitals West Campus The Woodlands 99 Har 18200 Katy Freeway 17600 Interstate 45 S dy T Houston, TX 77094 The Woodlands, TX 77384 oll Road Kingwood Glen Specialty Care Clear Lake Cy-Fair Cy-Fair (X-RAY & ULTRASOUND) (X-RAY & ULTRASOUND) 940 Clear Lake City Blvd., Suite 200 11777 FM 1960 West Webster, TX 77598 Houston, TX 77065 99 Texas Children’s Hospital Sugar Land Kingwood Glen West Campus (X-RAY & ULTRASOUND) (X-RAY & ULTRASOUND) 15400 Southwest Freeway, Suite 200 19298 West Lake Houston Pkwy., Suite 110 Upper Kirby Sugar Land, TX 77478 Humble, TX 77346 Westpark Tollway Texas Children’s Upper Kirby Bellaire Hospital – Texas Bellaire Medical Center (X-RAY & ULTRASOUND) (X-RAY only) 3023 Kirby Drive, Suite 201 6330 West Loop South, Suite 300 Houston, TX 77098 Bellaire, TX 77401 99 Sugar Land Clear Lake Radiology Order Form – Pediatric V6 5/2019.
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